Angiographic findings and clinical correlates in patients with cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry (original) (raw)
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Journal of the American College of Cardiology, 2003
The goal of this study was to describe the core laboratory angiographic findings of "SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK" (SHOCK) trial participants and to determine the relationship of angiographic parameters to one-year survival. BACKGROUND In the SHOCK trial, emergency revascularization improved one-year survival of patients with cardiogenic shock compared with initial medical stabilization including thrombolysis and intraaortic balloon counterpulsation.
Cardiogenic shock complicating acute myocardial infarction in the United States, 1979-2003
This SHOCK Study report seeks to provide an overview of patients with cardiogenic shock (CS) complicating acute myocardial infarction (MI) and the outcome with various treatments. The outcome of patients undergoing revascularization in the SHOCK Trial Registry and SHOCK Trial are compared. BACKGROUND Cardiogenic shock is the leading cause of death in patients hospitalized for acute MI. The randomized SHOCK Trial reported improved six-month survival with early revascularization.
Archives of Cardiovascular Diseases Supplements
HAL is a multidisciplinary open access archive for the deposit and dissemination of scientific research documents, whether they are published or not. The documents may come from teaching and research institutions in France or abroad, or from public or private research centers. L'archive ouverte pluridisciplinaire HAL, est destinée au dépôt et à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.
Pakistan Heart Journal, 2023
The objective of this study was to investigate the immediate and short-term mortality rates among patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS) who underwent primary percutaneous coronary intervention (PCI). Methodology: This observational study was conducted at a tertiary care cardiac center in Pakistan. We included consecutive patients diagnosed with STEMI complicated by CS who underwent primary PCI. We analyzed the clinical characteristics, management strategies, and in-hospital as well as short-term follow-up outcomes of the patients. Results: A total of 200 patients were included in the study, of which 74.5% (149) were male, and the mean age was 57.96 ± 12.52 years. The majority of patients were classified as Killip class III (64.0%, 128), while the remaining were classified as Killip class IV. On arrival, arrhythmias were observed in 37.5% (75) of the patients, 27.5% (55) were in cardiac arrest and 84.5% (169) required intubation. Intra-aortic balloon pump (IABP) placement was performed in 31.5% (63) of the patients, and temporary pacemakers (TPM) were placed in 18.5% (37). The in-hospital mortality rate was found to be 10.5% (21). During a mean follow-up period of 177 days (141.5-212.5), a cumulative major adverse cardiovascular event (MACE) was observed in 48% (96) of the patients, with an all-cause mortality rate of 28% (56). Additionally, re-infarction occurred in 7.5% (15) of the patients, and re-hospitalization due to heart failure was noted in 23.5% (47) of the patients. Our study revealed an in-hospital mortality rate of 10.5% following primary PCI in patients with CS. At approximately six months after the acute event, nearly half of the patients experienced MACE, with a notable mortality rate of 28%. These findings highlight the critical nature of CS and emphasize the need for further research and interventions to improve outcomes in this high-risk patient population.
American Heart Journal, 2001
based estimates of changes over time in the occurrence rates of cardiogenic shock remain extremely limited because the majority of data has been derived from single hospitals, specialty referral centers, or in the context of post-hoc analyses of randomized trials. In the absence of definitive treatment to re-establish flow in the infarctrelated coronary artery, hospital mortality associated with cardiogenic shock remains high. 4,10,13-16 Little change was observed in the death rate from this clinical syndrome in a population-based study in Worcester, Mass, carried out between the mid 1970s through the late 1980s. 11 More recent findings from this communitywide study suggest no change in the incidence rates of cardiogenic shock complicating AMI between 1975 and 1997 but a trend toward improved hospital survival in patients with cardiogenic shock in the mid to late 1990s compared with earlier periods. There has been an increasing trend to use more aggressive early therapeutic interventions in patients Despite recent advances in acute coronary care and benefits associated with early use of reperfusion strategies, cardiogenic shock complicating acute myocardial infarction continues to be associated with a poor shortterm prognosis. 1,2 The proportion of patients with acute myocardial infarction (AMI) having cardiogenic shock ranges between 5% and 15%, depending on the care seeking, demographic, and clinical characteristics of the varying samples under study. 1,3-10 Population-From the Background Limited recent data are available to describe the magnitude of, and temporal trends in, the incidence and case-fatality rates associated with cardiogenic shock complicating acute myocardial infarction. The purpose of this study was to examine recent (1994)(1995)(1996)(1997) trends in the incidence of, and hospital death rates from, cardiogenic shock complicating acute myocardial infarction from a large, multihospital national perspective.
Cardiovascular Ultrasound, 2008
Background: Echocardiography is widely used in the management of patients with cardiogenic shock (CS). Left ventricular ejection fraction (EF) has been shown to be an independent predictor of survival in CS. Tissue Doppler Imaging (TDI) is a sensitive echocardiographic technique that allows for the early quantitative assessment of regional left ventricular dysfunction. TDI derived indices, including systolic velocity (S'), early (E') and late (A') diastolic velocities of the lateral mitral annulus, are reduced in heart failure patients (EF < 30%) and portend a poor prognosis. In CS patients, the application of TDI prior to revascularization remains unknown. Objective: To characterize TDI derived indices in CS patients as compared to patients with chronic CHF. Methods: Between 2006 and 2007, 100 patients were retrospectively evaluated who underwent echocardiography for assessment of LV systolic function. This population included: Group I) 50 patients (30 males, 57 ± 13 years) with chronic CHF as controls; and Group II) 50 patients (29 males, 58 ± 10 years) with CS. Spectral Doppler indices including peak early (E) and late (A) transmitral velocities, E/A ratio, and E-wave deceleration time were determined. Tissue Doppler indices including S', E' and A' velocities of the lateral annulus were measured. Results: Of the entire cohort, the mean LVEF was 25 ± 5%. Cardiogenic shock patients demonstrated significantly lower lateral S', E' and a higher E/E' ratio (p < 0.01), as compared to CHF patients. The in-hospital mortality in the CHF cohort was 5% as compared to the CS group with an in hospital mortality of 40%. In the subset of CS patients (n = 30) who survived, the mean S' at presentation was higher as compared to those patients who died in hospital (3.5 ± 0.5 vs. 1.8 ± 0.5 cm/s). Conclusion: Despite similar reduction in LV systolic function, CS patients have reduced myocardial velocities and higher filling pressures using TDI, as compared to CHF patients. Whether TDI could be a reliable tool to determine CS patients with the best chance of recovery following revascularization is yet to be determined.
Circulation, 2009
Background-Limited information is available about potentially changing and contemporary trends in the incidence and hospital death rates of cardiogenic shock complicating acute myocardial infarction. The objectives of our study were to examine 3-decade-long trends (1975 to 2005) in the incidence rates of cardiogenic shock complicating acute myocardial infarction, patient characteristics and treatment practices associated with this clinical complication, and hospital death rates in residents of a large central New England community hospitalized with acute myocardial infarction at all area medical centers. Methods and Results-The study population consisted of 13 663 residents of the Worcester (Mass) metropolitan area hospitalized with acute myocardial infarction at all greater Worcester medical centers during 15 annual periods between 1975 and 2005. Overall, 6.6% of patients developed cardiogenic shock during their index hospitalization. The incidence rates of cardiogenic shock remained stable between 1975 and the late 1990s but declined in an inconsistent manner thereafter. Patients in whom cardiogenic shock developed had a significantly greater risk of dying during hospitalization (65.4%) than those who did not develop cardiogenic shock (10.6%) (PϽ0.001). Encouraging increases in hospital survival in patients with cardiogenic shock, however, were observed from the mid-1990s to our most recent study years. Several patient demographic and clinical characteristics were associated with an increased risk for developing cardiogenic shock. Conclusions-Our findings indicate improving trends in the hospital prognosis associated with cardiogenic shock. Given the high death rates associated with this clinical complication, monitoring future trends in the incidence and death rates and the factors associated with an increased risk for developing cardiogenic shock remains warranted. (Circulation. 2009;119:1211-1219.)
The American Journal of Cardiology, 2009
Myocardial infarction (MI) often develops when thrombosis occurs at lesions which have not previously been flow-limiting. However, the development of cardiogenic shock complicating acute myocardial infarction in such circumstances has received little attention. We studied the characteristics of 15 patients with cardiogenic shock who had no flow-limiting angiographic stenosis compared to 767 patients with at least one stenosis, who were enrolled in the SHOCK Trial and Registry. Compared to patients with at least one flow-limiting stenosis, patients with no flow-limiting stenosis were less likely to have pulmonary edema on chest x-ray (29% v 62%, P=0.008), and to have white ethnicity (53% v 82%, P = 0.011), and had lower median highest creatine kinase levels (702 v 2731 u/l; P = 0.018). For SHOCK Trial patients 1-year survival was 49% for patients with at least one flow-limiting stenosis and 71% for those with no flow-limiting stenosis (P= 0.268).
ESC Heart Failure, 2021
Aims This study aims to evaluate the impact of the combination of cardiogenic shock (CS) and cardiac arrest (CA) complicating non-ST-segment elevation myocardial infarction (NSTEMI). Methods and results Adult (>18 years) NSTEMI admissions using the National Inpatient Sample database (2000 to 2017) were stratified by the presence of CA and/or CS. Outcomes of interest included in-hospital mortality, early coronary angiography, hospitalization costs, and length of stay. Of the 7 302 447 hospitalizations due to NSTEMI, 147 795 (2.0%) had CS only, 155 522 (2.1%) had CA only, and 41 360 (0.6%) had both CS and CA. Compared with 2000, the adjusted odds ratios (ORs) and 95% confidence interval (CIs) for CS, CA, and both CS and CA in 2017 were 3.75 (3.58-3.92), 1.46 (1.42-1.50), and 4.52 (4.16-4.87), respectively (all P < 0.001). The CS + CA (61.2%) cohort had higher multiorgan failure than CS (42.3%) and CA only (32.0%) cohorts, P < 0.001. The CA only cohort had lower rates of overall (52% vs. 59-60%) and early (17% vs. 18-27%) angiography compared with the other groups (all P < 0.001). CS + CA admissions had higher in-hospital mortality compared with those with CS alone (aOR 4.12 [95% CI 4.00-4.24]), CA alone (aOR 1.69 [95% CI 1.65-1.74]), or without CS/CA (aOR 22.66 [95% CI 22.06-23.27]). The presence of CS, either alone or with CA, was associated with higher hospitalization costs and longer hospital length of stay. Conclusions The combination of CS and CA is associated with higher rates of acute non-cardiac organ failure and in-hospital mortality in NSTEMI admissions as compared with those with either CS or CA alone.
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Nitric oxide synthase inhibitors in post-myocardial infarction cardiogenic shock-an update
Clinical Cardiology, 2006
Cardiogenic shock (CS) in acute myocardial infarction, after successful coronary angioplasty, still carries a case fatality rate of 50%. These patients succumb to a systemic metabolic storm, superimposed on extensive myocardial necrosis and stunning. Nitric oxide (NO) overproduction contributes to the pathophysiology of this morbid state. Current data regarding the physiologic effects of NO and nitric oxide synthase (NOS) inhibitors on the cardiovascular system are reviewed. Clinical trials assessing the safety and efficacy of NOS inhibitors in CS are summarized.
The European Journal of Health Economics
Background The CULPRIT-SHOCK trial compared two treatment strategies for patients with acute myocardial infarction and multivessel coronary artery disease complicated by cardiogenic shock: (a) culprit vessel only percutaneous coronary intervention (CO-PCI), with additional staged revascularisation if indicated, and (b) immediate multivessel PCI (MV-PCI). Methods A German societal and national health service perspective was considered for three different analyses. The cost utility analysis (CUA) estimated costs and quality adjusted life years (QALYs) based on a pre-trial decision analytic model taking a lifelong time horizon. In addition, a within trial CUA estimated QALYs and costs for 1 year. Finally, the cost effectiveness analysis (CEA) used the composite primary outcome, mortality and renal failure at 30-day follow-up, and the within trial costs. Econometric and survival analysis on the trial data was used for the estimation of the model parameters. Subgroup analysis was perform...
Annals of Noninvasive Electrocardiology
Background: The most common aetiology of cardiogenic shock (CS) is acute coronary syndrome (ACS), but even up to 20%-50% of CS is caused by other disorders. ST-segment deviations in the electrocardiogram (ECG) have been investigated in patients with ACS-related CS, but not in those with other CS aetiologies. We set out to explore the prevalence of different ST-segment patterns and their associations with the CS aetiology, clinical findings and 90-day mortality. Methods: We analysed the baseline ECG of 196 patients who were included in a multinational prospective study of CS. The patients were divided into 3 groups: (a) ST-segment elevation (STE). (b) ST-segment depression (STDEP). (c) No ST-segment deviation or ST-segment impossible to analyse (NSTD). A subgroup analysis of the ACS patients was conducted. Results: ST-segment deviations were present in 80% of the patients: 52% had STE and 29% had STDEP. STE was associated with the ACS aetiology, but one-fourth of the STDEP patients had aetiology other than ACS. The overall 90-day mortality was 41%: in STE 47%, STDEP 36% and NSTD 33%. In the multivariate mortality analysis, only STE predicted mortality (HR 1.74, CI 95 1.07-2.84). In the ACS subgroup, the patients were equally effectively revascularized, and no differences in the survival were noted between the study groups. Conclusion: ST-segment elevation is associated with the ACS aetiology and high mortality in the unselected CS population. If STE is not present, other aetiologies must be considered. When effectively revascularized, the prognosis is similar regardless of the ST-segment pattern in ACS-related CS.
Cardiogenic shock in ACS. Part 2: Role of mechanical circulatory support
Nature reviews. Cardiology, 2012
This Review explores contemporary circulatory support in profound postinfarction cardiogenic shock. Frequently, death is the only alternative to implantation of a blood pump, so prospective randomized trials of device versus medical treatment are unacceptable and evidence is derived from clinical experience. Irrespective of ACC/AHA and European guidelines, no study has shown survival benefit for the intra-aortic balloon pump in patients with established shock. In the past 10 years, the safety and durability of mechanical blood pumps has improved considerably. New temporary and long-term rotary pumps have transformed outcomes for patients with acute heart failure. For urgent resuscitation, outreach salvage, and transportation extracorporeal membrane oxygenation (ECMO) is a reliable, but time limited, first step. ECMO decompresses the venous system, provides flow, and ensures oxygenation, but does not unload the failing left ventricle. Myocardial stunning takes days, and sometimes wee...
ESC Heart Failure, 2020
AimsUrgent revascularization is the mainstay of treatment in acute coronary syndrome (ACS) related cardiogenic shock (CS). The aim was to investigate the association of angiographic results with 90‐day mortality. Procedural complications of percutaneous coronary intervention (PCI) were also examined.Methods and resultsThis CardShock (NCT01374867) substudy included 158 patients with ACS aetiology and data on coronary angiography and complications during PCI procedure. Survival analysis was conducted with Kaplan–Meier curves and Cox regression analysis. Median age was 67 ± 11 years, and 77% were men. During 90‐day follow‐up, 66 (42%) patients died. Patients with one‐vessel disease (n = 49) had lower mortality than patients with two‐vessel (n = 59) or three‐vessel (n = 50) disease (25% vs. 48% vs. 52%, P = 0.011). Successful revascularization [Thrombolysis in Myocardial Infarction (TIMI) Flow 3 post‐PCI) was achieved more often in survivors than non‐survivors (81% vs. 60%, P = 0.019). ...
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European Journal of Heart Failure, 2010
Aims Despite improvement in prognosis for ST-elevation myocardial infarction (STEMI) patients, mortality remains high in STEMI patients presenting with cardiogenic shock (CS). Right ventricular (RV) dysfunction is an established independent predictor for adverse prognosis in STEMI patients without CS. The purpose of our study was to determine the prognostic value of RV dysfunction on admission in STEMI patients presenting in CS. Methods and results 292 consecutive STEMI patients with CS on admission were treated by primary percutaneous coronary intervention (PCI) from January 1997 through March 2005. RV function was assessed by measurement of tricuspid annular plane systolic excursion (TAPSE) on early echocardiography in 184 of 292 patients. RV dysfunction was defined as a TAPSE of ≤14 mm. RV dysfunction was present on early echocardiography in 70 of 184 patients (38%). The Kaplan-Meier estimate for overall 4-year survival was 57%. Kaplan-Meier estimates for 4-year survival in patients with and without RV dysfunction were 33% and 73%, respectively (p <0.001). Cox-regression analysis revealed a hazard ratio of 2.1 (95% CI 1.3-3.4, p=0.002) for RV dysfunction when adjusted for age, glucose and LVEF<40%. In patients with and without RV dysfunction, the right coronary artery (RCA) was the infarct-related artery (IRA) in 41% and 28% of patients, respectively (p=0.06). Conclusion In STEMI patients presenting with CS on admission and treated with primary PCI, RV dysfunction as assessed by echocardiography is an independent predictor for long term mortality.
Journal of the American College of Cardiology, 2000
OBJECTIVES: We sought to determine the outcomes of patients with cardiogenic shock (CS) complicating non-ST-segment elevation acute myocardial infarction (MI).BACKGROUND: Such patients represent a high-risk (ST-segment depression) or low-risk (normal or nonspecific electrocardiographic findings) group for whom optimal therapy, particularly in the setting of shock, is unknown.METHODS: We assessed characteristics and outcomes of 881 patients with CS due to predominant left ventricular (LV) dysfunction in the SHOCK Trial Registry.RESULTS: Patients with non-ST-segment elevation MI (n = 152) were significantly older and had significantly more prior MI, heart failure, azotemia, bypass surgery, and peripheral vascular disease than patients with ST-elevation MI (n = 729). On average, the groups had similar in-hospital LV ejection fractions (approximately 30%), but patients with non-ST-elevation MI had a lower highest creatine kinase and were more likely to have triple-vessel disease. Among patients selected for coronary angiography, the left circumflex artery was the culprit vessel in 34.6% of non-ST-elevation versus 13.4% of ST-elevation MI patients (p = 0.001). Despite having more recurrent ischemia (25.7% vs. 17.4%, p = 0.058), non-ST-elevation patients underwent angiography less often (52.6% vs. 64.1%, p = 0.010). The proportion undergoing revascularization was similar (36.8% for non-ST-elevation vs. 41.9% ST-elevation MI, p = 0.277). In-hospital mortality also was similar in the two groups (62.5% for non-ST-elevation vs. 60.4% ST-elevation MI). After adjustment, ST-segment elevation MI did not independently predict in-hospital mortality (odds ratio, 1.30; 95% confidence interval, 0.83 to 2.02; p = 0.252).CONCLUSIONS: Patients with CS and non-ST-segment elevation MI have a higher-risk profile than shock patients with ST-segment elevation, but similar in-hospital mortality. More recurrent ischemia and less angiography represent opportunities for earlier intervention, and early reperfusion therapy for circumflex artery occlusion should be considered when non-ST-elevation MI causes CS.
Management of cardiogenic shock complicating myocardial infarction
Intensive care medicine, 2018
Up to 10% of acute coronary syndromes are complicated by cardiogenic shock (CS) with contemporary mortality rates of 40-50%. The extent of ischemic myocardium has a profound impact on the initial, in-hospital, and post-discharge management and prognosis in this patient population. Individualized patient risk assessment plays an important role in determining appropriate revascularization, drug treatment with inotropes and vasopressors, mechanical circulatory support, intensive care support of other organ systems, hospital level of care triage, and allocation of clinical resources. This review will outline the underlying causes and diagnostic criteria, pathophysiology, and treatment of CS complicating acute coronary syndromes with a focus on (a) potential therapeutic issues from the perspective an interventional cardiologist, an emergency physician, and an intensive care physician, (b) the type of revascularization, and
Cardiogenic shock caused by right ventricular infarction
Journal of the American College of Cardiology, 2003
The purpose of this study was to determine the characteristics and outcomes of patients with acute myocardial infarction (MI) complicated by cardiogenic shock due to predominant right ventricular (RV) infarction. BACKGROUND Although RV infarction has been shown to have favorable long-term outcomes, the influence of RV infarction on mortality in cardiogenic shock is unknown.
Cardiogenic shock complicating myocardial infarction: an updated review
British Journal of Medicine and Medical Research, 2013
The current review aimed to highlight the update management in patients with ischemic Cardiogenic shock (CS) and its impact on mortality. We reviewed the literature using search engine as MIDLINE, SCOPUS, and EMBASE from January 1982 to October 2012. We used key words: "Cardiogenic Shock". This traditional narrative review did not expand to explore the mechanical complications or other causes of CS. There were 7193 articles assessed by 3 reviewers. We excluded 4173 irrelevant articles, 1660 non-English articles and 93 case-reports. The current review evaluated 888 articles (880 studies and 8 meta-analyses) that were tackling ischemic CS from different points of view before and after the era of SHOCK trial. Ischemic CS remains the most serious complication of acute MI, being associated with high mortality rate both in the acute and long-term setting, despite the advances in its pathophysiology and management. Further randomized trials and guidelines are needed to save resources and lives in patients sustained ischemic CS.
ESC Heart Failure, 2020
AimsUrgent revascularization is the mainstay of treatment in acute coronary syndrome (ACS) related cardiogenic shock (CS). The aim was to investigate the association of angiographic results with 90‐day mortality. Procedural complications of percutaneous coronary intervention (PCI) were also examined.Methods and resultsThis CardShock (NCT01374867) substudy included 158 patients with ACS aetiology and data on coronary angiography and complications during PCI procedure. Survival analysis was conducted with Kaplan–Meier curves and Cox regression analysis. Median age was 67 ± 11 years, and 77% were men. During 90‐day follow‐up, 66 (42%) patients died. Patients with one‐vessel disease (n = 49) had lower mortality than patients with two‐vessel (n = 59) or three‐vessel (n = 50) disease (25% vs. 48% vs. 52%, P = 0.011). Successful revascularization [Thrombolysis in Myocardial Infarction (TIMI) Flow 3 post‐PCI) was achieved more often in survivors than non‐survivors (81% vs. 60%, P = 0.019). ...
Trends in cardiogenic shock: report from the SHOCK Study
European Heart Journal, 2001
We analysed time trends in patient characteristics, management, and outcomes of cardiogenic shock complicating acute myocardial infarction in the international, prospective SHOCK Trial Registry and pre-study Registry.
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